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Nick Trout
Nick Trout is a Diplomate of the American and European Colleges of Veterinary Surgeons and a staff surgeon at Angell Animal Medical Center in Boston.
Wellness: Healthy Living
… and how to avoid them
In my line of work as a veterinary surgeon, I don’t need a weatherman to tell me that summer has officially arrived. One glance at our list of ER admissions is all it takes. Outdoor parties and barbecues are perfect opportunities for flirty, furry, four-legged socialites to work the crowd and make new friends. The downside is that dogs’ curiosity, their heightened sense of smell and their gift for the art of scavenging can spell trouble. Use the following list of usual suspects to prepare, educate your guests or consider a change in menu plans.
Yards: With friends coming and going, there’s always a risk your dog may become disoriented or run off through an open gate. Make sure the perimeter is secure (and everyone knows to keep it that way), or have your dog stay indoors in a quiet, familiar room. And despite your desire to show off your canine Michael Phelps, if it’s a pool party, your dog should stay out of the water, as a crowd of swimmers can create panic and distress.
Bones: It doesn’t matter whether they’re from chicken wings or pork ribs, cooked meat bones cause all sorts of problems, especially if they get lodged in the mouth, throat or esophagus. Terriers in particular have been proven to be at higher risk (which is probably more behavioral than anatomical, but still true). Make sure your guests have somewhere to dispose of their carnivorous waste rather than using your dog as a trash can.
Skewers: Tasty morsels pierced by a sharp wooden skewer may be a convenient and eye-catching way to serve grilled meat or veggies, but the inedible (though deliciously aromatic) stick can prove irresistible to an inquisitive canine, and is guaranteed to wreak havoc on an unsuspecting intestinal tract. More trash bags, please!
Corn Cobs: There’s something about the size and diameter of a corn cob that makes for a snug fit in the canine small intestine, frequently resulting in an obstruction and an expensive trip to the operating room. Be vigilant about picking up leftovers and repositioning plates perched on table edges at the level of a curious snout.
Chocolate: A compound called theobromine found in chocolate can be potentially toxic to dogs, stimulating the heart and nervous system, sometimes with fatal consequences; an overdose is more likely in small breeds. If you know your dog has ingested chocolate, call your vet immediately. If your dog appears excited, or is restless, panting or vomiting, get to your nearest veterinary hospital. If ingestion occurred within two hours and you are seeing none of these signs, vomiting can be induced; administer 3 percent hydrogen peroxide, 1 teaspoon for every 10 pounds [4.5kg] of body weight, by mouth.
Fruit and Nuts: Grapes and raisins (dried grapes) can be extremely toxic to some dogs. In one report, four to five grapes were toxic in an 18-pound dog. If you suspect ingestion, call your veterinarian immediately. Apple cores can become lodged in the canine esophagus; peach pits have a knack for blocking the intestines; and macadamia nuts (plain or in cookies) can cause weakness, clumsiness, vomiting, muscle pain and joint swelling. Fortunately, most cases of macadamia toxicity can be managed with supportive care at home.
Not So Fun Stuff: The combination of a really hot barbecue grill and the desire to get to what’s on offer can overwhelm all canine self-control. Keep your dog away from the grill and nearby raw meats and seasonings. Collect trash frequently and secure it in closed containers. Come nighttime, glow sticks are fun … unless your dog chews through to the toxic contents inside. Candles (a safe distance from happy tails) are a better option.
Fireworks: Call me a party-pooper, but if you want to set off fireworks, don’t invite the dog.
Wellness: Health Care
Back from the Brink
The first time I saw Mugsy, he was under anesthesia, prepped for surgery; huge patches of skin over his legs, chest and flanks were beginning to slough and surgical intervention was required. “Is that what I think it is?” I asked Dr. Khorzad, the ER attending in charge of the case.
“Yep. Necrotizing fasciitis,” she replied, avoiding the more sensational and fear-mongering synonym: “flesh-eating disease.”
Mugsy was a gregarious, four-month-old male Shar Pei who had suddenly developed a dime-sized swelling on his chest.
“I thought it was just a bug bite,” said Mugsy’s owner, Chuck. But within 24 hours, his boisterous puppy had collapsed and become septic, and he was in excruciating pain.
Though the media plays up the concept of invisible bugs munching their way through tissue, the disease typically starts out with a minor injury, or even no identifiable trauma. Bacteria inoculated under the skin produce toxins and protein-destroying enzymes capable of cleaving skin from underlying fat and fascia.
“Now he’s doing better,” said Khorzad, as one of our residents began removing dead and dying flesh. “Good job I didn’t reach the owner when I wanted to put him to sleep.”
Her comment sent me backtracking through Mugsy’s history to discover how a failure to communicate had saved the dog’s life.
Shortly after his admission, Mugsy had taken a turn for the worse; his blood pressure plummeted and his pain became intractable. Given his blood work, clinical parameters and response to therapy, Khorzad was convinced that Mugsy could not survive. Ready to recommend humane euthanasia over suffering, she called Chuck, urging him to get to the hospital as soon as possible. But Chuck didn’t pick up. Every call went to voice mail.
It turned out that Chuck was in the middle of a “Tough Mudder” event, running up and down an intense army-style obstacle course in rural New Hampshire. When he finally listened to his messages some five hours later, he jumped into his car and headed straight for the hospital, still covered in mud. Amazingly, by the time he arrived, Mugsy had done the unthinkable. His puppy was more comfortable and his fever was beginning to subside. Mugsy actually wanted to eat.
Chuck told me, “When we first came through the ER, I lay down with him and said, ‘If you’re going to fight, I’ll fight with you.’ As weak as he was, he placed his paw on my hand. I knew he didn’t want to give up. During the race, I wore an armband with his name on it. I didn’t know whether I would be strong enough to complete the course, but I reckoned that if Mugsy could fight, then so would I.”
Roughly one in four people die from necrotizing fasciitis; many are subjected to multiple surgeries, including limb amputation. Fortunately, in dogs, nearly 90 percent survive. Mugsy required only one major procedure, managed to keep all four legs and came back to make a full recovery. Today, he is a healthy one-year-old, with a few lengthy scars to show for his brush with death.
I asked Chuck and Dr. Khorzad what they learned from the five hours that made all the difference.
“I know what would have happened,” said Chuck, “but Dr. Khorzad was always totally up-front with me. A while back, I got in a car accident and damaged the tendons in my hand. Doctors said I’d never catch a baseball in a glove again. Guess what?”
Chuck didn’t dwell on the kismet of being incommunicado. It was enough to be an optimist, a fighter—and, as he said, “it’s not over ’til it’s over.”
I know how it feels to see a dog you had given up on, a lost cause, come back from the brink of death. It’s a humbling and haunting experience. Dr. Khorzad did not make a mistake. Hindsight is not a prognostic tool. She made a call in real time, and as I see it, her fallibility defined her honesty, prioritized her desire to stop suffering. She saw the lesson as a new perspective on future cases.
“As the years pass, I am more and more willing to give a chance to the cases that have a low chance of recovery.” It’s the mindset of a clinician who never ceases to be amazed by the power of canine determination. It’s the silent whisper in an ear, the invisible tap on the shoulder, the reminder that—as was the case with Mugsy—it’s not over ’til it’s over.
Wellness: Health Care
It’s about time.
Every so often after an exhaustive consultation, I am the lucky recipient of a peculiar compliment: “I wish you were my doctor!” When I was a young veterinarian, I was thrilled to be held in higher esteem than my colleagues in human medicine. Now, years later, I see the sleight of hand in a trick that flatters my profession at the expense of another.
It’s all about time. Time is critical to people’s sense that their dogs are receiving better quality heath care than they get, not least because much of what vets do takes longer. Veterinarians deal with “signs,” clinical findings that we touch, hear, see, smell and, if we’re unlucky, taste. MDs have the additional benefit of “symptoms,” their patients’ verbal communication of abnormal sensations or changes in bodily functions. This means that MDs can pick up on subtleties, aches and twinges, whereas dogs have to wait until a problem becomes grossly visible, palpable, malodorous, audible or debilitating to a sufficient degree that people finally realize something is not quite right.
Denied the luxury of the spoken word, veterinarians can only interpret the language of animal signs. Pediatricians, who encounter similar problems with young children, are forced to interrogate parents for answers, but similarities end when we approach a dog who does not share his owner’s regard for the man or woman in the white coat. In my world, nothing happens when I say “open wide,” hoping to inspect canine tonsils. Examinations require trust, trust takes time and, with so many new smells and sounds, the distractions are endless.
No wonder our style of medicine seems more personal. Dog owners feel less hurried because, thankfully, we don’t have a choice. I’m certain MDs are just as sympathetic, but they can save time via direct communication—and, for the most part, are less likely to be bitten.
Another major factor in veterinarians’ favor is the relatively small number of animals we serve compared to the volume of people seen by MDs. In an article in the Boston Globe, Judy Foreman (a nationally syndicated health columnist) made some interesting comparisons between two quite different Boston hospitals: Massachusetts General and my place of work, the Angell Animal Medical Center. Mass General sees 1.5 million outpatients a year, compared to about 50,000 at Angell. Patients at Mass General speak about 60 different languages, proving that the spoken word is not always that helpful (although that’s 60 better ways to communicate than I have), and its average number of inpatients at any given time is 800, compared to about 60 at Angell.
What this all means is that vets have more time for their patient and the spokesperson paying the bill. Fewer inpatients mean that blood tests, biopsy results and radiology reports are quick to turn around and their interpretation and communication to the owner is faster, all of which reinforces our superior service. We have more time to discuss the case, to leave written updates, to take pages, to return calls promptly, to go over discharge instructions in more detail. No wonder we look good. In my world, veterinarians are reimbursed for time spent with the family as well as the patient. It is an integral part of the service we offer.
Clearly, the human medical profession has taken notice of the superior patient satisfaction among their veterinary counterparts. A company called Customer Service University (CSU) has produced a 13-minute video called It’s a Dog’s World that highlights the consequences of poor healthcare service. Bob and his Golden Retriever, Max, are injured while out for a walk. As the CSU website boasts, “Bob is treated like a dog at his healthcare facility, and Max gets the royal treatment at his vet’s office.” The unfortunate logic of “being treated worse than a dog” is not lost on me, but I believe most viewers will find some unsettling truths in a tale that ends with Bob’s wife thanking an anonymous doctor for a followup call; the attentive clinician is unmasked as the vet when we hear suggestions on ways to hide medication in dog food.
These days, I have an answer ready when an owner drops the “I wish you were my doctor” compliment: I offer a smile, shake my head and say, “I’m pretty sure your dog would disagree. Ask his opinion the next time I take his temperature!”
Wellness: Healthy Living
Companionship Through the Ages
Whether his correspondence comes via snail mail or email, Duncan, my father, closes it with love, and always includes the names of his dogs sending love my way. When I was younger, this sentimental touch made me laugh and sometimes embarrassed me. But over time, I came to appreciate this sign-off—an endearing reminder that a family is always the sum of its individual members, be they human or animal.
That’s why the real impact of Sasha’s demise didn’t hit me until I read an email ending in a simple “love, Mum and Dad.” Sasha had been 14, a good age for a Labrador, and now Duncan, 71, claimed he had finally reached a bad age to be thinking about another dog. Had the man who seemed incapable of a future without a dog by his side finally hung up his leash?
Many of my elderly clients crave the companionship of a dog. They love the responsibility, the reason for getting up in the morning, the easy conversation and the unparalleled emotions these creatures draw from us. But they fear not being physically able to care for a dog and not providing sufficient exercise. Most of all, they worry about who will look after their dog when they pass.
Connie Schultz, a Pulitzer Prize–winning journalist, is a columnist for the Cleveland Plain Dealer. When I contacted her regarding this dilemma, she was brimming with ideas. “What if middle schools and high schools had a program to train young people how to help the elderly care for their pets? Everyone wins. The elderly get help walking and feeding their pets. The young people get to cuddle with the dogs and feel useful. Throw in school credit, cross-generational friendships and you’ve got a terrific way to generate a sense of community in our increasingly isolated lives.”
Given that my father lives in rural England, I went with a different approach. “Why not adopt an older dog?” I asked. “Unlike a new puppy, what you see is what you get. They’re already housetrained and ready to go for walks.”
Truth is, older shelter dogs are always looking for good homes because they are more difficult to adopt. People see an older dog and wonder if they’ve been relinquished because of behavioral or expensive health problems. Connie had another great idea.
“What about a national registry for elderly pet owners? They could register when they adopt, alerting family and friends so that when they pass, there is a system in place to find new homes. This way, future adopters would know the reason for the pet’s abandonment.”
In fact, Dogs Trust, the largest dog-welfare charity in the UK, already has a free service known as the Canine Care Card, whereby they guarantee to take on the responsibility of caring for and rehoming a dog should the worst happen to its owner. Even if they cannot find a suitable home, they promise to look after the dog for the rest of its natural life.
How did I find out about Dogs Trust?
“You read my mind, son. There’s such a large hole in my life without Sasha. I still go out alone for our walk, talk to her, imagine she’s with me, but I hate walking alone. An older dog would be grand. Mind, she’d have to be good around sheep.”
There’s always been a period of mourning, time for my father to let the world know he was grieving a significant loss. Still, there’s hope for another dog in his future, a female no less. I wonder how long before a new name finds its way to the last line of his letters.
Wellness: Health Care
A Vet’s Perspective
Like so many of life’s firsts, first dogs have a special place in our hearts. Patch, the handsome and powerful German Shepherd of my youth, was no exception. I was a teenager when Patch’s healthy body began to deteriorate. At the time, I resigned myself to our family vet’s opinion that my 13-year-old dog was suffering from the chronic effects of hip dysplasia. However, with hindsight (and a veterinary education), I realize that Patch must also have been suffering from degenerative myelopathy (DM), a debilitating neurological disease of the spinal cord, which robbed him of his dignity during his final year of life.
From his belly forward, he was a normal dog—bright, eager to please and utterly without pain, defying time gracefully. Not so the back half, which was progressively turning into Jell-O. It was as though his body was controlled by two actors in a dog costume: the guy at the front was alert and coordinated, the guy at the back was falling-down drunk. I watched my best friend become trapped inside a dying body, the absence of pain making it worse, somehow. His heart was perfect. Mine was breaking.
Fast-forward 30 years, and it’s a clumsy Newfoundland named Tonka who has me thinking about Patch again. That’s because Tonka displays similar signs: stumbling and progressive weakness of the back end.
“Her spinal MRI was clear,” said her owner, “and that new test for DM was negative. So this has to be about her hip problems, right?”
As it happens, I agreed, but my confidence that Tonka could not be suffering from DM was based on more than the “new test,” a DNA analysis recently offered by the Orthopedic Foundation for Animals (OFA), working with the University of Missouri.
As a 2009 study* revealed, DM has an associated genetic marker, SOD1. To simplify the process, let’s say the abnormal gene influencing DM is A, and its normal equivalent is N. Since every dog gets one copy of each gene from each parent, there are three possible combinations—N/N, a dog who is highly unlikely to contract or pass on DM to its offspring; A/N, a dog with a low risk for contracting DM but the capacity to pass on an abnormal gene; and A/A, an at-risk dog who will always pass on a mutated gene to its offspring.
The test is simple, requiring only a saliva swab from the inside of the dog’s cheek and payment of $65, which covers the cost of the test kit, processing and registration in the OFA database.
Without doubt, this is a wonderful tool in the fight against DM, but as the University of Missouri takes pains to point out on its website, having two copies of the mutated gene does not necessarily result in disease. Many A/A dogs are completely normal, although they may develop DM later in life. Other now-unknown risk factors may also be involved.
The list of DM-affected breeds is extensive; among those on it are Golden Retrievers, Boxers, Corgis, Chesapeake Bay Retrievers, Bernese Mountain Dogs, Pugs, Poodles, Rhodesian Ridgebacks and, of course, German Shepherds.
To date, there is no scientifically proven treatment for DM. The best hope is prevention via responsible breeding programs guided by knowledge and understanding of an individual dog’s genetic makeup.
To be absolutely certain a dog has DM, the affected part of the spinal cord must be examined under a microscope, something that unfortunately cannot be done on a living dog. Barring that, the gold standard diagnostic tool is an MRI of the spine, says neurology specialist Dr. Avril Arendse, my colleague at MSPCA-Angell.
And this brings me back to Tonka and why I felt confident that all I had to worry about were her poor hips. Yes, her DM genetic test was normal, but more importantly, her spinal MRI ruled out the possibility of disk disease, tumors and other neurological causes of her clinical signs. Looking forward, Tonka has plenty of options, unlike my much-loved Patch, who, to this day, gave me my first and best lesson for owners nursing dogs with disabling diseases: empathy.
Wellness: Health Care
A Kinder Cut? Advances in spay procedures
As a colleague of mine once said, “a spay is a procedure routinely performed, but it is not a routine procedure.” In the U.S., “spay” refers to the surgical removal of the ovaries and uterus. In Europe, however, removal of just the ovaries (ovariectomy) appears to be the most popular sterilization technique. Why are my European colleagues doing things differently, and is there evidence to suggest that they’re right? Is it possible to achieve the same surgical result using a less-complicated, less-involved procedure?
It’s been proven that an ovariectomy, which can be done via laparoscopy (or “keyhole” surgery), requires a smaller incision. Still, to date, no one has proven that removing both the uterus and the ovaries is more painful than taking just the ovaries, and no one has compared complication rates between the two surgical techniques.
However, other aspects have been assessed. In the Journal of the American Veterinary Medical Association, Michael DeTora, DVM, and Robert J. McCarthy, DVM, MS, DACVS, examined the two approaches.* Judging by their report, removing only the main hormone producers — the ovaries — has a lot going for it. Here are a few of their leading points.
One of the big benefits to spaying is the decreased incidence of mammary gland tumors, the most common tumor in female dogs. Sterilize before the first heat and your dog is 200 times less likely to develop breast cancer when compared to a sexually intact dog. Taking or leaving the uterus will not change this risk; rather, the benefit comes from removing the ovaries and their sex hormones.
It has been argued that there are two important reasons to remove the uterus. The first is the risk of developing pyometra, a uterine infection. Typically, pyometra occurs in dogs who have not been spayed and is attributed to the long-term influence of sex hormones, particularly progesterone, produced by the ovaries. In a study of 135 dogs, 66 had a regular spay and 69 had only the ovaries removed. There were no episodes of pyometra in either group up to 11 years after the surgery. In other words, leaving the uterus does not mean your dog will get a uterine infection. Remove the ovaries and you remove the source of progesterone, which means that pyometra cannot occur.
The second concerns the risk of leaving a redundant organ behind, potentially exposing the dog to a future uterine tumor. This appears reasonable until you consider that uterine tumors are extremely rare. In one study, just 11 of nearly 35,000 female dogs had a tumor of the uterus, and only one of these was cancerous. Benign uterine tumors are slow growing, don’t spread to other organs and are easily cured with surgery. The chance of your dog succumbing to uterine cancer is a lot slimmer than your lifetime risk of being killed in a car crash.
This leaves urinary incontinence, one of the most frustrating side effects of spaying. Reportedly, as many as one in five sterilized female dogs will have a tendency to dribble urine after surgery. Exactly why this happens is poorly understood, but the presence or absence of the uterus appears to make no difference.
As a veterinarian, one of my most important roles is to help owners make informed health-care decisions for their companion animals. Evidence-based medicine suggests that there is no recognized disadvantage to taking just the ovaries and leaving the uterus behind. Though inertia is always the biggest barrier to change, I may have a chance to influence the choice when asked the time-honored question, “What would you do if this were your dog?”
“Easy. Take the ovaries. Leave the uterus.”
Wellness: Health Care
A Vet’s Perspective
Every day in veterinary emergency rooms across the country, shocked, distraught and overwhelmed dog owners face tough decisions. In addition to medical complexities and ambiguities, they deal with guilt, fear, grief and, sadly, money. But for Kathy Noons and her seven-year-old Boston Terrier, Tessie, it was all about hope.
Although Ms. Noons had asked her dog-walker to keep Tessie leashed, the woman often let her run loose with other dogs, and Tessie clearly loved it. But then came the phone call: The dogwalker had lost Tessie. It was January. The little dog was found the next morning, miles away, lying in a cemetery.
When Tessie arrived at the Angell Animal Medical Center ER, she had a temperature of 86.7°F (normal is around 101°F), the bones of her pelvis were shattered and, as a result of spinal trauma, she was paralyzed and incontinent.
Barely responsive, Tessie was so cold that warming her up had to be done slowly over the course of several hours to avoid further shocking her system. Blood and urine were drawn and tested, she was X-rayed and an ultrasound was performed. Throughout it all, she received intravenous fluids and medications for pain.
Eventually, Ms. Noons was presented with a long list of negatives that, when added up, suggested that euthanasia would be the kindest course of action. As she retold it, “That’s when I said, ‘C’mon, throw me a bone (no pun intended),’ [and] one doctor told me what I needed to hear. She said there’s always a chance.”
It took a few days for Tessie to stabilize, and that’s when I got involved. Ms. Noons later told me her biggest fear was that I would refuse to operate … that I would tell her it was futile. To be honest, it crossed my mind. Despite surgery, the risk of permanent nerve damage, incontinence and an inability to stand, let alone walk, was significant. But sometimes, if you put everything back in place, screw it all together and take a leap of faith, tissue heals. Tessie’s injuries were really bad, but not hopeless.
Though the odds were slim at best, I believed surgery offered her at least the possibility of a cure. An uncertain prognosis can be like a bad trip to Vegas, a gamble in which the only way out is through — risky, all or nothing. But that’s the hand we were dealt, and it was the one we played.
My involvement in Tessie’s recovery, while important, was brief and, to be honest, secondary. I reconstructed her broken pelvis with plates and screws, but the critical-care doctors and attentive technicians gave her the chance Ms. Noons sought. Yes, it takes a team to heal a “humpty-dumpty” dog, but in the jigsaw puzzle of putting Tessie back together, I only did one or two of the corners. Tessie’s primary-care team did all the tricky, thankless stuff.
Once Tessie was released from the hospital, Ms. Noons was committed to giving her the best possible chance to recover. Diapers, pain meds, hydrotherapy, acupuncture: Whatever Tessie needed, Ms. Noons provided. Ultimately, this level of commitment, this steadfast conviction, paid off. Three months after surgery, Tessie was running around, chasing other dogs and fully continent. Why this dog made it and a dozen others with the exact same injuries would not, I can’t say. Maybe a dog who can survive being hit by a car and a cold January night in Boston has an extra helping of luck.
“She was always a source of pride,” says Ms. Noons. “People would stop me and want to play with her. When they saw her in a diaper, barely able to walk, I could tell they were thinking, Is it fair what you’ve done to your dog?”
“How’s it feel today,” I say, “when you meet these naysayers in the street?” “It’s nice to be smug; I’m not going to say it isn’t. I’m proud of her, being fresh, going after bigger dogs. My princess is back.”
Ms. Noons marvels at what we did for Tessie and, though I appreciate (and am humbled by) her gratitude, it’s far more than I deserve. Perhaps the hands-on nature of surgery, the physicality of mending broken bones, the instant gratification of postoperative X-rays, makes it look as though the doctor with the scalpel created the cure. Truth is, I’m as amazed as she is, and under no illusion; in this magic act, I was nothing more than a willing assistant.
Wellness: Health Care
Second Opinion
I consider myself to be an optimist, a “glass-half-full” veterinarian. So why was I so worried about Zeus, a four-year-old Great Dane mix?
“He’s been lame for a couple of months,” said Jeff.
“And he’s very active,” added Jeff ’s girlfriend, Adrian. “We run six miles, five times a week, and go to the dog park for an hour or so every evening.”
Zeus had been referred to me for a torn cruciate ligament in his left knee — a perfectly reasonable diagnosis. But what I was seeing didn’t align with it. For starters, he held his withered leg totally off the ground, and when I palpated his knee, it felt stable. His X-rays confirmed the presence of arthritis, but it was mild, not enough to account for his apparent discomfort.
“Something doesn’t add up,” I said, trying not to sound like a pessimist. “I’m worried that I may be missing a bigger problem.”
Jeff seemed wary and Adrian looked alarmed, though she later confessed that she had suspected as much.
“I’d like to anesthetize Zeus and feel the knee when he’s totally relaxed, then take another X-ray. If everything jibes, we’ll go straight to surgery and fix the problem.”
However, my examination while Zeus was anesthetized failed to expose joint laxity, and I began to worry that the changes I saw on the X-ray weren’t the result of arthritis but rather, a tumor in the joint.
“I’d like to take a biopsy,” I told Jeff. If he was losing patience, he kept it to himself. When the results came back normal, I had to make another difficult phone call — difficult because I still didn’t have an answer.
“I don’t want this to be something bad,” I said, “but I’d also hate to put Zeus through a surgery that doesn’t address the real problem.”
“What do we do now?” Jeff’s flat tone revealed his waning confidence.
“Let’s put a scope, a camera, inside the knee. If the ligament’s damaged, I’ll see it and repair the knee. If not, I’ll keep hunting for what’s wrong.”
I tried to put myself in Jeff and Adrian’s position; they must’ve felt as though they were dealing with a cagey Dr. Doom. They wanted me to fix their dog, not speculate on the ways in which Zeus’ problem has failed to match up with my textbooks. Would they seek another opinion? After all the money they’d spent, poor Zeus was still not better.
Fortunately, I got my chance to look inside the joint, discovered that the ligament was partially but significantly torn, and verified the need for corrective surgery. Even so, when Zeus returned for his six-week recheck, I braced for the worst: a dog still struggling to get around on three legs.
Sometimes, it’s good to be wrong. Zeus was bouncy, fresh, eager to play and using the leg very well for this stage of his recovery. Now that we were out of the woods, I felt as though I could speak frankly with Adrian about my concerns, and encourage her to come clean about her own perspective on the process I’d put them through.
“It was frustrating,” she said. “Jeff and I definitely got into a lot of … disputes. We thought about not doing surgery, about going somewhere else. In the end, I realized you were just being thorough.”
I made sure Adrian knew how grateful I was that she had kept the faith. Though I’m a surgeon, I’m not married to the adage, “cut to cure.” Despite my initial negativity, I had done my best to be honest, voice my fears, take time to listen, be rational about my approach and, most of all, make sure they understood that my hesitation was rooted in what mattered most: doing right by Zeus.
“When did you know he had turned the corner?” I asked.
“The first week was tough,” said Adrian. “I was still worried. But Zeus loves two things in life. He loves to chase his tail, and the day I saw him spinning around on his back legs trying to catch it, I cried because I knew my boy was back.”
“What’s the second thing?”
“His orange ball. For the first time in months, he found it and brought it to me because he wanted to play fetch. No doubt about it, he’s on the road to recovery.”
I smiled and kept a reprimand about premature ball-chasing to myself.
Wellness: Health Care
Treating chronic pain in dogs.
I see it all the time. it might be a yellow Lab cursed with crunchy, stiff elbows; a Rottweiler with knees that refuse to bend; or a German Shepherd who circles forever before daring to lie down. Degenerative arthritis in our canine companions is a common, debilitating and frustrating problem, especially for older dogs. Though some dog owners opt for surgical solutions like joint replacement, others think twice about the merits of major surgery, particularly in the later stages of a dog’s life. Thus the questions: Are there alternative ways to effectively manage my dog’s pain? Can I restore quality of life and, given these tough economic times, not break the bank? My colleague at Boston’s Angell Animal Medical Center, Lisa Moses, VMD, DACVIM, CVMA, heads up the center’s specialty Pain Medicine Service, and I turned to her for insights, which she generously provided.
“We almost always use a multimodal approach, combining different techniques and/or types of drugs to target the different ways in which pain is produced. It’s not about adding more and more, it’s about treatments complementing and enhancing one another.”
Like me, the first thing Dr. Moses focuses on is weight. Studies have shown that an 11 to 18 percent reduction in body weight significantly decreases the severity of hind-limb lameness. It’s not easy, but weight loss has huge potential to reduce arthritis-associated pain. When recommending supplements, Dr. Moses is a fan of the omega-3 (n-3) fatty acids. “You need to make sure you get the right dose for your dog. Check with your vet, use a dog-specific preparation and choose a supplement that separates the fatty acid from vitamin D,” she cautions. Then there are glucosamine and chondroitin sulphate.
In broad terms, these compounds are thought to target some of the destructive enzymes that cause arthritic pain. Dr. Moses uses an injectable supplement, Adequan (polysulfated glycosaminoglycan), but remains cautious about all the unregulated products for oral administration, regardless of how much anecdotal success they claim. “Sometimes we are so desperate to help our best friends that we’re willing to believe anything will work. We’re the ones susceptible to the placebo effect, not our dogs,” she says.
Non-steroidal anti-inf lammatory drugs (NSAIDs) are the mainstays of pain management, especially for canine arthritis. According to Dr. Moses, “Regardless of what you read on the Internet, NSAIDs such as Rimadyl, Metacam and Deramaxx remain the best class of drugs. We know the risks, we know how to monitor our patients and we know how to minimize side effects.”
Both Dr. Moses and I strive to use the smallest effective dose to restore function. As she notes, “Clearly, in older dogs, use of NSAIDs depends on kidney and liver function, but [all things being equal] I often use them in conjunction with other drugs.”
Amitriptyline, amantadine and gabapentin may also enhance pain relief in combination with other analgesics. Every dog’s pain is individual and needs to be addressed as such.
It’s not all about drugs, however. Acupuncture, another useful modality, has no side effects, though, as Dr. Moses says, it’s important for owners to understand that the response to acupuncture is not as immediate as the response to drugs: “It’s a cumulative change in the way pain is signaling.” Typically, Dr. Moses (who is also certified in veterinary medical acupuncture) treats dogs weekly for up to two months. “Very few cases show no improvement on acupuncture, though some owners feel the improvement is insufficient.”
Physical therapy is another option. Dr. Moses advocates aquatherapy, provided by a trained physical therapist in a controlled environment and heated water, with the dog wearing a floatation device. I agree; letting your arthritic Labrador dive into the local pond on the weekend doesn’t have the same effect. The goal of aquatherapy is to carefully build muscle strength and boost a dog’s quality of life, not pound away on sore joints while chasing ducks or tripping over rocks.
Then there’s transcutaneous electrical nerve stimulation and laser therapy. When I asked her if she was sold on these, she replied that the jury’s still out. “I think these treatments hold promise, but as far as I know, there’s no peer-reviewed evidence that proves they’re effective.”
The proverbial bottom line? It takes time to make changes in the nervous system. The owner has to have faith and not keep jumping from one option to another. Dr. Moses generally uses a treatment plan for four to eight weeks before trying something else. “Think about it — the way your dog shows discomfort often waxes and wanes. If you change the treatment plan too frequently, it’s hard to know whether it’s working or not.”
And how do you know a treatment’s working? Look for markers of normalcy, says Dr. Moses. “It might be your dog’s ability to once again get up on your bed. It might be a male dog once more cocking his leg to pee. My favorite comes from an owner who said he knew his Miniature Poodle was responding to treatment when the dog tried to hump his wife’s leg!”
Wellness: Health Care
Second Opinion
As an englishman, I’m used to fielding questions about my homeland, but earlier this year, my jaw dropped when a patient asked me, “Who’s Kate Middleton?” It amazed me that anyone could be unaware of the future king of England’s bride. I couldn’t help thinking, How did you manage to avoid this story? Where have you been hiding? Little did I know that my next patient, a three-year-old Australian Shepherd named Cyrus, would show me how easy it is to be uninformed.
“He’s been lame in his front right for about five months,” his owner, Jaime, told me. “It gets worse with exercise.” The symptoms seemed consistent with a shoulder injury. It may be a sweeping generalization, but problems involving toes, wrists and elbows — hinge joints — tend to reveal themselves with pain, swelling or an abnormal range of motion. Ball-and-socket joints, like the shoulder, rely a little more heavily on muscles, tendons and ligaments for stability, which makes the shoulder vulnerable to repetitive sports injuries. Throw in this breed’s innate desire to exercise, and you have a recipe for low-grade, niggling lameness.
“I’d like to sedate Cyrus, get some ultrasonographic images of his shoulder joint and, if indicated, give him a steroid shot.”
Jaime agreed, and we set a date for the imaging. Later, when she dropped off Cyrus, she gave me a printout she thought I would appreciate. Hidden in Cyrus’s record, I discovered a document stating that he carried two copies of the mutant MDR1 gene, and a list of the dozens of drugs (including most sedatives) that would be seriously detrimental to his health.
Where had I been hiding? I read the information as though I were a green veterinary student struggling to assimilate important new stuff. What was the MDR1 gene? Did I miss that lecture? Surely Cyrus was not the first blue merle Aussie I had seen since graduating more than 22 years ago.
It turns out I was not completely ignorant. I recalled warnings about the mysterious sensitivity of Collies and related breeds to a variety of drugs, especially the anti-parasitic ivermectin. Not so long ago, the reason behind this sensitivity was discovered: the multi-drug resistance gene (MDR1) codes for a protein integral to pumping a variety of drugs from the brain back into the blood.* Dogs who carry two mutant MDR1 genes (mutant/mutant) lack this all-important protein, which means that many drugs can linger in the brain and cause life-threatening side effects. Even dogs with only one normal copy of the gene (mutant/normal) can be more vulnerable to drug toxicity.
The MDR1 mutat ion notably affects Collies — roughly three out of four Collies in the U.S. carry mutant MDR1 — Longhaired Whippets, Shelties, Aussies and Old English Sheepdogs. (Washington State University’s website provides a comprehensive list of drug susceptibilities and instructions for having your dog’s DNA tested via a blood sample or cheek swab; ) Naturally, I wondered why I had never witnessed adverse drug reactions in any of the listed dog breeds whom I had cared for in the past. Could I just have been lucky and only had normal/normal dogs?
When I asked my colleagues in anesthesia, they gave me the same withering look I had dispensed so easily only days earlier. Of course they knew about MDR1, and altered dosages and chose drugs accordingly. Sedatives can be used safely if the dose is reduced by 25 to 50 percent. Perhaps this was the answer. Maybe my natural proclivity for using the lowest possible dose to achieve sedation had inadvertently prevented dangerous side effects.
As for Cyrus, despite his genetic anomaly, his procedures went well; the suspected tendon injury was confirmed and he responded nicely to the steroid injection. There were no problems with his sedation, unless you count the professional embarrassment I felt for not knowing about his DNA. The good news was that this dog reminded me that I cannot possibly know everything, that I must be receptive to learning and that I am grateful for others who know so much more than I.
More importantly, it’s going to be a while before I think any question is too dumb to ask.
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